Same-Day Discharge Program Shows Promise in Elective Benign Foregut Surgery

Same-day home recovery (SHR) was feasible and safe for patients who underwent elective benign foregut surgery, a prospective cohort study showed.

Among 1,248 such patients participating in a Northern California healthcare system’s SHR program, 11.5% were discharged on the same day of surgery prior to implementation in 2018, which increased to 26.9% after the program was implemented in 2019, then to 49.3% in 2020, and finally reaching 72.6% in 2021, reported Swee H. Teh, MD, of Northern California Kaiser Permanente (NCKP) in San Francisco, and colleagues.

The program was found to be feasible across all three types of benign foregut surgical procedures — fundoplication for gastroesophageal reflux disease, Heller myotomy for achalasia, and hiatal hernia repair, the authors noted in JAMA Surgery.

Importantly, there were no significant differences between patients in the SHR group and those who were not discharged the same day for 7-day rates of postoperative emergency department visits (11.8% vs 10%, P=0.44), hospital readmissions (3.5% vs 4.5%, P=0.51), and reoperations (1.7% vs 3.5%, P=0.15).

The same was true for 30-day rates:

• Emergency department visits: 17% vs 16.9% (P=0.79)
• Readmissions: 4.5% vs 7.2% (P=0.13)
• Reoperations: 2.4% vs 5% (P=0.07)

Since SHR has become the standard of care for many types of surgical procedures, it may have the potential to become standard practice for common benign foregut procedures as well, Teh’s group noted. Because of advances in modern medicine, SHR has become an option for a wide range of procedures, from minimally invasive surgeries to orthopedic procedures that once only allowed for inpatient care.

“A successful SHR program is built on patient education about surgical and anesthetic techniques, multimodal pain management, good home support, management of anxiety (both patient and surgeon), consistent expectations, and increased use of postoperative telehealth-based communication,” the authors wrote.

“An added benefit of home recovery is the minimization of hospital-acquired adverse effects, such as nosocomial infection and other post-hospital syndromes, as well as decreased utilization of limited hospital resources, especially during the COVID-19 pandemic,” they added.

However, “while the program was considered cost-effective within the Kaiser system, considering the high rate of emergency department visits, readmissions, and reoperations, the cost model would need to be closely examined outside of this health maintenance organization environment,” noted Marco Patti, MD, and Fernando Herbella, MD, both of the University of Virginia in Charlottesville, in an accompanying editorial.

Furthermore, “it is debatable if patients are more comfortable or safer after being discharged home a few hours after a major operation,” they wrote. “While in the hospital, they can be monitored and given pain and antiemetic medications by professionals.”

For this study, Teh and colleagues examined data on 1,248 patients who underwent benign foregut surgery across 19 centers of the NCKP integrated healthcare system from January 2017 to September 2021. Of these patients, 558 underwent surgery before the SHR program was implemented and 690 underwent surgery after the program was implemented.

Patient candidacy for the program was based on care team assessments including operative findings, the ability to ingest liquids without nausea or vomiting, and stable vital signs, among others. Patient characteristics were similar between groups. Mean age was 60, 61% were women, 68% were white, and 39% had a BMI greater than 30.

Among the 690 patients in the SHR program, only 288 were discharged on the same day as their surgery and participated in phone or video visits within 24 to 48 hours after discharge. The remaining 402 patients were significantly older (mean age 61 vs 57) and had a longer average duration of surgery (3.02 vs 2.23 hours).

The 30-day mortality rate was 0.16%, with one death in each group.

Teh and team acknowledged that the use of administrative data that relied on accurate surgical reports was a limitation to their study. Furthermore, data on comorbidities and perioperative outcomes were not available.